From the Guidelines
Oral medications for chronic hyperkalemia primarily include potassium binders such as patiromer (Veltassa) and sodium zirconium cyclosilicate (Lokelma), with patiromer being a preferred option due to its efficacy and safety profile as shown in recent studies 1. When managing chronic hyperkalemia, it is essential to consider the potential benefits and risks of each medication.
- Patiromer is usually started at 8.4 g once daily and can be titrated up to 25.2 g daily; it should be taken with food and separated from other medications by at least 3 hours.
- Sodium zirconium cyclosilicate begins with 10 g three times daily for 48 hours, followed by 5-10 g once daily maintenance; it can be taken with or without food. These medications work by binding potassium in the gastrointestinal tract and facilitating its elimination through feces. Key considerations for treatment include:
- Regular monitoring of serum potassium levels, typically weekly until stabilized, then monthly.
- Addressing underlying causes of hyperkalemia, which may include adjusting medications like ACE inhibitors, ARBs, or potassium-sparing diuretics.
- Following a low-potassium diet, limiting foods like bananas, oranges, potatoes, and tomatoes. Recent studies have shown that patiromer is effective in maintaining normokalemia in patients with advanced CKD and resistant hypertension, as well as in patients with diabetes and CKD, including those with HF receiving RAASis 1. Additionally, sodium zirconium cyclosilicate has been shown to be effective in reducing serum potassium levels in patients with hyperkalemia, including those with CKD, HF, and/or diabetes or those receiving RAASis 2. However, the most recent and highest quality study suggests that patiromer may be a preferred option due to its efficacy and safety profile 1.
From the FDA Drug Label
LOKELMA is indicated for the treatment of hyperkalemia in adults. For initial treatment of hyperkalemia, the recommended dose of LOKELMA is 10 g administered three times a day for up to 48 hours. For continued treatment, the recommended dose is 10 g once daily. The recommended maintenance dose range is from 5 g every other day to 15 g daily.
Oral medication options for managing chronic hyperkalemia:
- Sodium zirconium cyclosilicate (LOKELMA): The recommended dose is 10 g once daily, with a maintenance dose range of 5 g every other day to 15 g daily 3.
- Patiromer (Veltassa): The mean daily doses were 13 grams and 21 grams in patients with serum potassium of 5.1 to < 5.5 mEq/L and 5.5 to < 6.5 mEq/L, respectively 4.
From the Research
Oral Medication Options for Managing Chronic Hyperkalemia
The following oral medications are available for managing chronic hyperkalemia:
- Patiromer: a potassium binder that facilitates fecal excretion of potassium, with a dose-dependent potassium-lowering effect 5, 6, 7, 8
- Sodium zirconium cyclosilicate (ZS9): a potassium binder that binds potassium in the gastrointestinal tract, with a dose-dependent potassium-lowering effect 5, 9, 8
- Sodium polystyrene sulfonate (SPS): a potassium binder that enhances potassium excretion, but is associated with serious gastrointestinal adverse effects 5, 9
Key Characteristics of Oral Medications
- Patiromer and ZS9 are designed to address the treatment gap in managing hyperkalemia, with a lower risk of adverse effects compared to SPS 5
- Patiromer has been shown to be effective in decreasing serum potassium, preventing recurrence of hyperkalemia, and reducing RAASi discontinuation 6
- ZS9 has been demonstrated to have a clear evidence of a dose-dependent potassium-lowering effect and the ability to initiate, maintain, or titrate RAASi 5
- SPS is associated with limited evidence base, with only two small clinical trials indicating potassium reduction in chronic hyperkalemia 5
Safety and Efficacy
- Patiromer and ZS9 have been shown to be generally safe and well-tolerated, with a low risk of adverse effects 5, 6, 7
- SPS is associated with a higher risk of adverse effects, including rare GI damage 5, 9
- Further studies are needed to evaluate the safety and efficacy of these medications, particularly in patients with multiple medications or high-risk populations 5, 8